pattern recognition in neuroimaging and genetics may lead to new ways for identifying ADHD

(68). Potentially these approaches may alter current nosological classification systems, as
aetiological factors appear to influence dimensions of psychopathology rather than categorical
disorders.

Assessment of ADHD and comorbidity

Diagnosis of ADHD is complicated by the high rates of comorbid psychiatric disorders and
presence of more general mental health symptoms. Adults with ADHD are at increased risk of
developing depressive disorders, bipolar disorder, dysthymia, anxiety disorders, antisocial
personality disorder, BPD, and SUDs (69). Furthermore, it can be difficult to distinguish
between ADHD and other psychiatric disorders because there is a high rate of overlapping
symptoms (10). Accurately diagnosing ADHD in adults is, however, clinically important,
because of the severe consequences of undiagnosed and untreated ADHD, or providing patients
with ineffective or poorly targeted treatments.
One reason for diagnostic confusion is the nature of the clinical syndrome of ADHD, which
shares characteristics with other common adult mental health disorders. These include clinical
features associated with adult ADHD that do not form part of the current DSM-5 or ICD-10
diagnostic criteria. Examples include poor concentration, distractibility, restlessness,
overtalkativeness, sleep problems, irritability, impulsiveness, and low self-esteem. However, in
this regard adult ADHD is no different from other common mental health disorders, many of
which also share a similar set of overlapping symptoms. One clear distinction from most adult-
onset disorders is the typical early onset and trait-like persistence of ADHD symptoms, which
reflect what someone is usually like, rather than a change in premorbid mental state and episodic
course. Since diagnostic symptom overlap is common for adult mental disorders this is unlikely
to provide a full explanation for underdiagnosis of ADHD. A more general issue is lack of
awareness and training in the diagnosis and clinical management of ADHD among adult mental
healthcare professionals.
When considering the relationship of ADHD to comorbid symptoms, syndromes, and
disorders, there are three main categories to consider.
1. ADHD mimics other conditions. Either because of overlap with core ADHD symptoms
such as restlessness and poor concentration, or because of characteristic associated features
of ADHD such as emotional instability, low self-esteem, and sleep problems (Box 19.2),
ADHD may mimic other mental health conditions. This group is important to identify
because they are likely to respond to appropriate drug treatment for ADHD.
2. Neurodevelopmental traits and disorders. These are often seen to develop alongside
ADHD. These include autism spectrum disorder, specific reading difficulties (dyslexia), and
developmental coordination disorder (dyspraxia). Comorbid neurodevelopmental
comorbidity traits can have a marked impact on functional impairment but, unlike ADHD
symptoms would not be expected to respond to treatments with ADHD medication.
3. ADHD as a risk factor for development of comorbid mental health disorders. Comorbid
disorders may develop as a complication of ADHD. For example, children with ADHD are
at greater risk for the development of SUDs, anxiety, depression, and personality disorders
(including antisocial and borderline), as well as criminal behaviour. The effects of treating
adult ADHD in the presence of comorbid mental health disorders are not well researched.
Current evidence is based mainly on the experience of expert consensus. For example,
although we know that emotional dysregulation often improves alongside core ADHD
 symptoms during the treatment response to stimulants, there is limited information on the
efficacy of treatment in ADHD cases comorbid with borderline or antisocial personality
disorders. Nevertheless, recent pharmacoepidemiological studies suggest that treating
ADHD can reduce criminal behaviour (70), substance abuse (71) and suicidal behaviour
(72).

Box 19.2 Symptoms and impairments of ADHD that can mimic other mental health disorders

Anxiety: worrying about performance deficits, excessive mind wandering, feeling

overwhelmed, feeling restless, avoidance of situations due to ADHD symptoms such as
difficulty waiting in queues or social situations requiring focused attention, sleep problems
linked to mental restlessness.
Depression: unstable moods, impatience, irritability, poor concentration, sleep disturbance,
low self-esteem.
Personality disorder (e.g. borderline and antisocial): chronic trait-like psychopathology
linked to behavioural problems, emotional instability, impulsive behaviour, poor social
relationships.
Bipolar disorder: restlessness, sleep disturbance, mood instability, ceaseless unfocused
mental activity.
Reprinted from The Lancet Psychiatry, 3, 6, Asherson P, Buitelaar J, Faraone SV et al, Adult attention-deficit hyperactivity
disorder: key conceptual issues, pp. 568–78. Copyright © 2016 Elsevier Ltd. All rights reserved.

Diagnostic considerations in complex cases of ADHD, depression, and personality disorder

The issues discussed may clearly complicate the assessment of ADHD in adults. It may be
difficult to diagnose ADHD in the presence of an ongoing depressive episode. Both disorders are
characterized by reduced ability to concentrate, inner feelings of restlessness or physical
agitation, low self-esteem, and sleep disturbances. Symptoms related to a depressive episode
should, however, remit, whereas symptoms of ADHD should be present continuously.
Because adults with ADHD often exhibit low self-esteem, low mood, affective lability and
irritability, these symptoms may sometimes be confused with dysthymia, cyclothymia, or bipolar
disorder and BPD (37). Finally, it is difficult to evaluate psychiatric symptoms, including
ADHD, in patients with ongoing alcohol or drug abuse. The SUD should ideally be treated or
stabilized before assessment of ADHD (8).
Personality disorders (especially cluster B) often co-occur with adult ADHD and are
particularly frequent with BPD (73). Moreover, ADHD in childhood has been reported to be
associated with an increased risk for the development of BPD in adulthood (73). In recent
studies, ADHD diagnosis in childhood was found in over 40% of adults in BPD samples (40, 74,
75). Furthermore, in the study by Philipsen and colleagues (39) 16.1% of the adult BPD sample
was diagnosed as having comorbid ADHD in adulthood, indicating that the presence of one of
the disorders should not necessarily exclude the other (39). On the other hand, the differential
diagnosis between ADHD and BPD can be difficult. There are several overlapping symptoms
between ADHD and BPD, including emotional instability, impulsivity (75), substance abuse,
low self-esteem, and disturbed interpersonal relationships (73). Diagnostic uncertainty may also
arise in females who do not present with the classical hyperkinetic type of ADHD in childhood
(73).
 BPD is characterized by additional symptoms, such as suicidal or self-mutilating behaviour,
unclear or disturbed self-image, stress-related paranoid symptoms, and chronic feelings of
emptiness, as well as by a tendency to become involved in intense and unstable relationships
with repeated emotional crises (potentially associated with excessive efforts to avoid
abandonment and a series of suicidal threats or acts of self-harm) (73). However, disturbed ‘self-
image, unclear aims and internal preferences’ can also be found in ADHD, evoked by negative
experiences and affected interpersonal relationships, e.g. at school, work, and home, resulting in
criticism and rejection (73). However, chronic suicidality and parasuicidal behaviour is generally
not part of ADHD, and, despite chaotic relationships in both disorders, most clinicians agree that
the interpersonal functioning of patients with BPD and ADHD differs significantly, with fewer
difficulties in establishing a therapeutic relationship in ADHD (73).

Conclusions
Overall, there is now a considerable evidence base regarding the clinical presentation, diagnosis
and treatment of adults with ADHD. However, the impact of ADHD on adult psychopathology is
still not sufficiently well recognized within adult mental health services and there is a continued
educational need to support development of diagnostic and treatment services (8, 10). It is now
clear that ADHD should be recognized in the same way as other common adult mental health
conditions, and that failure to recognize and treat ADHD is detrimental to the wellbeing of many
patients seeking help for mental health problems. Despite this progress, there is a growing
awareness of the limitations of current psychiatric nosology (76), and further research is needed,
particularly in the evaluation and clinical management of ADHD in the context of comorbidities.

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